AB1512 CENTRAL RETINAL ARTERY OCCLUSION (CRAO) LEADING TO BILATERAL BLINDNESS; DUE TO BOTH ARTERITIC AND NON-ARTERITIC ISCHEMIC OPTIC NEUROPATHY
Authors: S. Sunari.Subasinghe@gmail.com, C. Biyanwila, O. Temizsoylu, K. Ramesar
Journal: Annals of the Rheumatic Diseases (2022)

Background Giant cell arteritis (GCA) is a large vessel vasculitis which is common in the elderly. It affects the cranial branches of the aorta, commonly superficial temporal, posterior ciliary and retinal arteries. Hence blindness can be one of the dreaded complications of the disease which makes prompt diagnosis and treatment of utmost importance. Sometimes atypical presentations and concurrent pathologies can make the timely diagnosis of the disease difficult. Therefore it is very important for clinicians to be vigilant of the varied presentations of the GCA and coexisting vascular risk factors. Objectives A 78-year-old Caucasian male was presented with acute onset blindness of the left eye. It started as few blotchy patches in the peripheral visual field and gradually became diffuse visual loss over a few days. He denied any headache, temporal tenderness, tongue or jaw claudication or symptoms of polymyalgia rheumatica. Following ophthalmology review he was diagnosed to have CRAO with marked disc pallor without any evidence of retinal emboli. He was in sinus rhythm, no carotid bruits or cardiac murmurs were noted. His comorbidities were hypertension and hypercholesterolemia. He was assessed in the transient ischemic attack clinic for screening for vascular risk factors and started on anti platelets. Methods Three months later he re-presented with visual loss in the right eye. Apart from the mild tenderness of the right temporal region noticed when trimming his hair he had no symptoms of GCA. He was started on dual antiplatelets and urgently referred to ophthalmologist who diagnosed central retinal artery occlusion of right eye with clear demonstration of emboli in all the arcades of the central retinal artery. A temporal arterial biopsy was performed. Results His CRP was 19mg/l &amp; ESR was 18mm/hr initially. During the second presentation both ESR (35) and CRP (40) were further elevated. His carotid doppler did not show significant stenosis in internal carotid arteries. ECG at presentation was in sinus rhythm however 24 hour holter monitoring after involvement of both eyes showed paroxysmal atrial fibrillation (PAF). Transthoracic echocardiogram was normal. His temporal arterial biopsy showed destruction of the internal elastic lamina with lymphohistiocytic infiltration and occasional giant cells in keeping with a diagnosis of GCA. Patient was started on prednisolone 60 mg daily followed by a tailing off regime and antiplatelets were changed to anticoagulation due to PAF. His vision improved mildly, only in the right eye in the way of perception of hand movements. Conclusion CRAO is an ocular emergency and is the ocular manifestation of a stroke. The usual presentation is a painless unilateral visual loss leading to profound blindness and is commonly due to non arteritic causes like carotid artery stenosis, cardiogenic embolism, small vessel disease and rarely due to arteritic causes like GCA. Accurate identification of the aetiology is very important to avoid further recurrence. By consensus multiple retinal emboli usually excludes a diagnosis of GCA (1). However considering, the patient’s age and recurrence of CRAO while on antiplatelets led us to consider occult GCA. 21.2% of patients with GCA induced vision loss do not have any systemic symptoms of the disease (2) . Hence there should be a high index of suspicion when an elderly person presents with ischaemic ocular manifestations especially optic nerve and retinal ischaemia even in the presence of another plausible explanation like PAF. References [1]Hedges, TR. (2018) Central and branch retinal artery occlusion (internet) (Accessed 22 Jan 2022). Available at https://www.uptodate.com/contents/central-and-branch-retinal-artery-occlusion?search=central%20retinal%20artery%20occlusion&amp;source=search_result&amp;selectedTitle=1~28&amp;usage_type=default&amp;display_rank=1 [2]Sane, M. et al . (2014) Transient visual loss due to reversible ‘pending’ central retinal artery occlusion in occult giant cell arteritis. Eye (Lond ),28(11),1387–1390. Disclosure of Interests None declared